Respiratory

Part I:
Anatomy + Physiology
Respiratory System Anatomy

Gas exchange
The delivery of oxygen from the lungs to the bloodstream, and the elimination of
carbon dioxide from the bloodstream to the lungs. Occurs in the alveoli through
passive diffusion.
 Terminology
● Ventilation
○ Air movement in and out of the lungs
● Oxygenation
○ Oxygen in the bloodstream
● Perfusion
○ Oxygen in the tissues

Adventitious Breath Sounds

Work of Breathing
● How easy is it for your client to take a deep breath?
● Retractions
○ Note location and severity
○ Location
■ Subcostal
■ Intracostal
■ Supraclavicular
■ Traheal https://www.mountsinai.org/health-library/symptoms/nasal-flaring

● Nasal flaring
● Head bobbing
● Grunting

https://quotessitesusa.blogspot.com/2021/04/babys-chest-sinks-in-when-hiccuping.html
Low-flow Non-rebreather

Nasal Cannula

Simple face mask

High-flow
Venturi mask High flow nasal cannula
 Non-Invasive Ventilation

Invasive Ventilation
● Endotracheal tube
● Tracheostomy
● Mechanical ventilator
Ventilator Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.

Causes: Causes:
Client coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit

Endotracheal
Tube
What is an endotracheal tube (ETT)?
● Invasive, artificial airway used when the client is unable to protect their own
airway.

● Plastic tube inserted into the

tracheal through the mouth or
nose
● Maintains an airway to deliver
oxygen and positive pressure
to the lungs
● “Breathing tube”

Nursing Must Know

● After placement of an ETT, placement should be verified by a chest x-ray
● Assess for equal breath sounds bilaterally
○ The ETT can becomes displaced into the R main stem bronchus
○ Ensure that breath sounds are heard equally bilaterally or the tube may need to be
repositioned.
 Tracheostomy

What is a tracheostomy tube?

● An artificial airway used for
long-term needs.
● Stoma is made in the neck and the
tube inserted into the trachea.
● Breathing is through the
tracheostomy tube, not the nose and
mouth.
● Used for:
○ Tracheal obstruction
○ Slow vent weaning
○ Tracheal damage
○ Neuromuscular damage
Dressing and ties

Trach Care
● Infection prevention is key!
○ The natural defenses of the nose and mouth are bypassed - higher risk for infection
○ Daily trach care - inpatient, this is a sterile procedure.
● Position: Fowler’s or semi-Fowler’s
● Perform hand hygiene, don clean gloves.
● Remove soiled dressing. Don sterile gloves.
● Clean the tracheostomy site
○ Use sterile applicators or gauze dressings moistened with normal saline.
■ 1:1 NS and Hydrogen peroxide is used with some clients
○ Use each applicator/gauze once, then discard.
○ Dry cient’s skin
● Apply new sterile dressing
● Change tracheostomy ties
● Check tightness - ensure 1 finger can fit underneath
Suctioning
● Only suction to the pre measured depth
○ Suctioning too deep can cause damage or cause laryngospasm
○ Don’t suction longer than 10 seconds
● Some clients may need pre-oxygenated with 100% FiO2

Safety
● You must keep two back up trachs at the bedside incase of emergency
○ 1 of same size
○ 1 a half size smaller
● If the trach comes out, first try to insert the back up of the same size
● If unsuccessful, try to insert the half size smaller
 Chest Tubes

What is a chest tube?

● Tube inserted into the pleural space
of the lungs.
● Helps to remove air or fluid that has
caused the lung to collapse
● Also placed after cardiac surgery to
help drain blood and fluid from
around the heart.
Why would our client
need a chest tube?
● There is something in the pleural
space….and we need to get it out.
○ Air
○ Fluid
○ Blood
● This allows the lung to fully expand.

Drainage System Chambers

Nursing Considerations
● Always keep the drainage system below the level of the client's chest
● Ensure the tubing is free of kinks and draining freely
● There should be no dependent loops in the tubing
● Monitor the drainage
○ Color - serous - serosanguinous. Know WHY the client has a CT!
○ Odor - none
○ Consistency - thin-thick
○ Amount - no more than 100ml/hr. More? Call the doc!!
■ Mark hourly

What to do if the chest tube comes out

● Cover the site with a
sterile dressing
● Tape on 3 sides
○ Air can escape this way. If
you tape on 4 sides you
might cause a tension
pneumothorax
● Call the provider
● STAY WITH THE CLIENT
What to do if the tube comes out of the
atrium?
● Still in the client, but becomes disconnected from the collection chamber
● Place the end of the chest tube in a bottle of sterile water

Part II:
Respiratory Pharmacology
Bronchodilators
● Albuterol
● Theophylline
● Terbutaline
● Levosalbutamol
● Ipratropium

Albuterol
Therapeutic class: Bronchodilator; short acting beta 2 agonist

Indication: Asthma, COPD

Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation of

the smooth muscles in the airways

Nursing Considerations:

● Be very cautious when using in clients with heart disease, diabetes,

glaucoma, or seizures.
● Causes tachycardia
Terbutaline
• Therapeutic class: Selective Beta 2 adrenergic agonist.

• Mechanism of action: Blocks beta 2 adrenergic receptors in the respiratory system to cause
bronchodilation by inhibiting the release of hypersensitivity reaction products from mast cells.

• Indications:
• Rescue/Relief and maintenance drug for wheezing, SOB, and coughing caused by asthma.

• Nursing considerations:
• SE: shakiness, jitteriness, dizziness, drowsiness, sleep disturbances, weakness, headache,
nausea, vomiting tachycardia, hypertension, hyperglycemia. CNS overstimulation.
• Assess HR, BP, EKG, blood glucose
• Can be given orally, SC, or by inhaler. 4-6 hour duration. More SE with oral administration
because it requires higher dosage.
• Teach proper inhaler use

Inhalers
● Hold with mouthpiece down. DO NOT hold
upside down
● Seal lips tightly around mouthpiece.
● Inhale through the mouth slowly
● Press down on inhaler one time. One breathe
in = one puff of medication
● Continue inhaling while medication is
dispensed (will likely feel cold) - breathe
slowly and as deeply as possible.
● Shake prior to use
Spacer
● Connects to the mouthpiece
of the inhaler so the
nebulized medication goes
into the spacer first.
● Allows the client to more
easily breathe in the
medication - timing of the
breath is less important
● Wastes less medication
● Common in pediatrics

Practice Question
Which of the following comments by the client reflects an understanding of the proper use of a
metered-dose inhaler?

Select all that apply.

A. “I will be careful not to shake the canister before using it.”

B. “I will hold the canister upside-down when using it.”
C. “I will inhale the medication through my nose.”
D. “I will continue to inhale when the cold propellant is in my throat.”
E. “I will only inhale one spray with one breath.”
F. “I will activate the device while continuing to inhale.”
Answers: D, E, + F
Which of the following comments by the client reflects an understanding of the proper use of a
metered-dose inhaler?

Select all that apply.

A. “I will be careful not to shake the canister before using it.”

B. “I will hold the canister upside-down when using it.”
C. “I will inhale the medication through my nose.”
D. “I will continue to inhale when the cold propellant is in my throat.”
E. “I will only inhale one spray with one breath.”
F. “I will activate the device while continuing to inhale.”

Misc. Respiratory
● Montelukast
○ Leukotriene modifier
● Guaifenesin
○ Expectorant
● Acetylcysteine
○ Mucolytic
● Pseudoephedrine, phenylephrine
○ Decongestant
● Antitussives
○ Dextromethorphan
○ Codeine
Steroids
● Betamethasone
● Dexamethasone
● Cortisone
● Methylprednisolone

Methylprednisolone
Therapeutic class: Corticosteroids

Indication: Inflammation, allergy, autoimmune disorders

Action: Suppress inflammation and normal immune response

Nursing Considerations:

● Monitor for too much steroids

○ Cushing’s symptoms; buffalo hump
● Side effects
○ Immunosuppression
○ Hyperglycemia
○ Osteoporosis
○ Delayed wound healing
Antihistamines
● Histamine-1 blocker → block H1 receptors in CNS - stopy allergies!
○ Diphenhydramine

● Histamine-2 blocker → block production of stomach acid!

○ Famotidine
○ Ranitidine

Diphenhydramine
Therapeutic class: Antihistamine

Indication: Allergy, anaphylaxis, sedation

Action: Antagonizes effects of histamine, CNS depression

Nursing Considerations:

● Monitor for drowsiness

● Anticholinergic effects
 Part III:
Respiratory Disorders

Chronic Obstructive Pulmonary Disease

● A group of lung diseases that

block airflow and make it
difficult to breathe.
● Includes:
○ Emphysema
○ Chronic bronchitis
○ Asthma
● Damage is not reversible.
Assessment
● Barrel chest
● Accessory muscle use
○ Retractions
○ Nasal flaring
○ Tracheal tug
● Congestion
● Lung sounds
○ Diminished
○ Crackles
○ Wheezes
● Acidotic
● Hypercarbic
● Hypoxic
Treatment
● Be very careful with oxygen administration!
○ In the normal client, hypercarbia stimulates the body to breathe.
○ This client has been hypercarbic for an extended period of time
○ For them, hypoxia has become the driving factor to stimulate breathing
● Bronchodilators
● Chest physiotherapy
● Increased fluid intake
● Encourage pursed lip breathing to help expire completely.
● Eat small frequent meals to avoid overdistention of the stomach which
impedes the diaphragm.
Asthma
● A respiratory condition marked by spasms in the bronchi of the lungs, causing
difficulty in breathing.
● Chronic inflammation of bronchi and bronchioles.
● Excess mucus.
● Result of an allergic reaction or hypersensitivity.

Pathophysiology
1. Airway is abnormally reactive - heightened sensitivity
2. Trigger causes a response
3. Inflammation and excess mucus production occur
4. Bronchospasm decreases the airway diameter
5. Airflow becomes obstructed

After many asthma reactions, airway remodeling occurs which causes scarring
and changes to lung tissue.
Triggers
A - Allergens

S - Sport / Smoking

T - Temperature change

H - Hazards

M - Microbes

A - Anxiety

Assessment
● Shortness of breath
● Unable to speak
○ Evaluate how many works they can say before taking a breath
● Cough
● Increased work of breathing
○ Retractions
○ Tracheal tug
○ Head bobbing
● Wheeze
● Prolonged expiration
● Can’t hear any breath sounds? Complete obstruction.
Treatment - acute exacerbation
● Airway, breathing, circulation!!
● Airway
○ Intubate?
○ Adrenergic agonists
● Open up airway
● Albuterol
● Breathing
○ Oxygen administration
○ Theophylline - Bronchodilator
○ Ipratropium - Anticholinergic
○ Dexamethasone - Steroid
● Circulation
○ IV fluids

Complication - Status Asthmaticus

● Asthma attack that is refractory to
treatment
● Leads to severe respiratory failure
● Can progress to death if untreated
Treatment - long-term control
● Inhaled Corticosteroids
○ Budesonide & Fluticasone
○ Take daily
● Leukotriene modifiers
○ Montelukast sodium
○ Blocks leukotrienes from over responding to triggers
● Theophylline
○ Bronchodilator
○ Helps keep bronchioles open and prevent wheezing, but must be used regularly.
● Allergen control
○ Clean environment
○ Minimize dust, pet dander, and mold
○ No secondhand smoke

Pneumonia
● Inflammation of the lung affecting the alveoli
● Alveoli
○ Tiny air sacs of the lungs which allow for gas exchange
● Alveoli become filled with pus and liquid
Classifications
● Viral
○ Caused by viruses such as RSV, adenovirus, and influenza
● Bacteria
● Fungal
● Chemical irritation
● Aspiration
○ When foreign bodies such as food and secretions enter the lungs
○ Cause inflammation and infection leading to pneumonia

Diagnosis
● Chest x-ray
○ “Patchy infiltrates”
● Sputum culture
○ Will identify a bacterial source

https://www.mayoclinic.org/diseases-conditions/pneumonia/multimedia/chest-x-ray-showing-pneumonia/img-20005827
Assessment
● High fever
● Cough
● Tachypnea
● Crackles
● Chest pain
● Work of breathing
○ Retractions
○ Tracheal tug
○ Nasal Flaring
○ Grunting
○ Head bobbing

Treatment
● Maintain airway ● Chest physiotherapy
○ Suction
● Antipyretics
○ Monitor SpO2
● Monitor breathing ● Analgesia
○ Assess for increased work of breathing ● Cough suppressant
○ Provide support as needed ● Expectorants
○ Humidified oxygen ● Antibiotics if bacterial
● Maintain circulation ● Isolation
○ Monitor for dehydration
○ IVF if unable to tolerate PO
 NCLEX Question
The nurse is reviewing the discharge teaching with a family who will be taking their
12 year old diagnosed with pneumonia home today. Which of the following points
should they review? Select all that apply.

a. Encourage your child to drink lots of water.

b. Administer the full course of antibiotics, even if your child starts to feel
better.
c. Call your pediatrician if there is tan sputum when when child coughs
d. Administer ibuprofen if your child has a temperature greater than 100
degrees F.
e. If your child is breathing harder or faster, call your PHCP immediately

Answer: A, B and E
A is correct. It is appropriate teaching to have the parents encourage their child to drink lots of water. Pneumonia can
frequently cause dehydration, due to tachypnea and increased insensible fluid losses. Parents should encourage adequate
hydration to promote fluid and electrolyte balance while their child is recovering from pneumonia.

B is correct. It is very important to teach parents to administer the full course of antibiotics, even if their child starts to feel
better. If the parents stop administering antibiotics part of the way through the course, they will be promoting antibiotic
resistance and the chance that the infection could return.

C is incorrect. The parents do not need to call the pediatrician if there is tan sputum when the child coughs. This is a
normal finding of pneumonia and should be expected. If there is a new onset of green sputum, this could indicate the
development of a bacterial pneumonia and the need to call the pediatrician.

D is incorrect. While Ibuprofen does have some antipyretic properties, it is not the best choice of medication to treat a
fever. If the child has a temperature of 100 F, the parents should be educated to administer acetaminophen, which is the
first choice for an antipyretic medication.

E is correct. Any signs of increased work of breathing (tachypnea, retractions, accessory muscle use, grunting, etc.) need
to be reported and assessed by a provider immediately

NCSBN Client Need:

Topic: Health promotion and maintenance Subtopic:-

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Respiratory
Acute Respiratory Distress Syndrome
● “an acute condition
characterized by bilateral
pulmonary infiltrates and
severe hypoxemia in the
absence of evidence for
cardiogenic pulmonary
edema”

● Fluid collects in alveoli

● Deprives body of oxygen
Causes
Anything that causes an inflammatory reaction in the lungs!!

● Sepsis
● Trauma
● Burns
● Aspiration pneumonia
● Overdose
● Near drowning

https://digitalcommons.otterbein.edu/cgi/viewcontent.cgi?article=1143&context=stu_msn
Assessment
● Chest x-ray
○ Diffuse bilateral infiltrates
○ “Whited-out”
● Hypoxemia
○ Pale
○ Cool
○ Dusky
○ Mottled
○ Low SpO2

Treatment
TREAT THE UNDERLYING CONDITION

● Intubation and mechanical ventilation

○ High pressures
● Prone
● Prevent infection
○ VAP
● Prevent barotrauma
Pneumothorax
● Air or fluid collects in the
pleural space
● Presses down on the lung.

Causes
● Spontaneous
○ Occurs due to a disease process
● Traumatic
○ Blunt
○ Penetrating
○ Complication of a procedure
Assessment
● Shortness of breath
● Chest pain
● Desaturation
● Hypotension
● Tachycardia
● Check that the trachea is midline…

Treatment
● Needle decompression
● Chest tube

**Complication** - TENSION pneumothorax!

→ When air continues to enter the lungs, leak into the pleural space, and then
can’t leave!

→ It pushes on the lungs, trachea, and heart and starts shifting them to one side.

→Tracheal shift (check that the trachea is midline!)

 Pulmonary Embolism

What is a Pulmonary Embolism?

● Life threatening blood clot in the lungs
● Can be caused by an embolism from a vein entering the lung, or a clot during
surgery.
● The clot decreases perfusion causing hypoxemia
● Can lead to right heart failure if untreated.
Assessment
● Anxiety
● Dyspnea
● Chest pain
● Hypoxemia
● Rales
● Diaphoresis
● Hemoptysis

Treatment and Nursing Interventions

● Oxygen administration
● Positioning
○ High fowler’s
○ Promotes maximum lung expansion and assists with breathing
● Anticoagulants
● Thrombolytics
 Air embolism Pulmonary
● Positioning: embolism
○ Durant’s maneuver: Left lateral
trendelenburg ● Positioning
○ High fowler’s

NCLEX Question
The client had just given birth and is resting in the postpartum unit when
suddenly she feels a sharp pain in the chest and is having difficulty breathing.
Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate
of 24. She is suspected of having a pulmonary embolism. What should be the
initial action of the nurse?

A. Start an IV line.
B. Monitor the client’s blood pressure.
C. Draw up morphine sulfate.
D. Give oxygen via face mask at 8-10 liters per minute.
Answer: D
Choice D is correct. During a pulmonary embolism, circulation in the pulmonary bed is altered,
thus affecting the oxygenation of the client. Oxygen should be started immediately at 8-10 liters
per minute to decrease hypoxia.

Choice A is incorrect. Starting an IV line is necessary but it is not the priority.

Choice B is incorrect. Checking the client’s blood pressure is a necessary action, but it should not
be the first action for the nurse to take.

Choice C is incorrect. Morphine sulfate may be given for pain management; however, the nurse’s
initial action would be to provide oxygen.